Foundation of wisdom: “I don’t know”

How do you solve a complex problem such as poverty? You might begin by saying, “I don’t know.” It’s hard to admit where your knowledge ends and your ignorance begins unless you, like Socrates, believe an understanding of your ignorance to be the truest wisdom. It’s a philosophy doctors find hard to embrace when talking to patients, but, as Matt Morgan points out (doi:10.1136/bmj.l5918), “I don’t know” can be the trigger for a more nuanced and more honest conversation.

Esther Duflo and colleagues won this week’s Nobel prize for economics by breaking the poverty problem down into smaller, more manageable questions or “I don’t knows” such as the benefits of giving free deworming pills to children or hiring school teachers on short term contracts (https://www.bbc.co.uk/news/business-50039214). A subtext here is that investing in children’s health matters, a message that resonates with this week’s issue. In one of her last acts as England’s chief medical officer, Sally Davies published a national plan to halve childhood obesity by 2030. Harry Rutter and colleagues say this won’t happen without major investment or a change in our social, economic, policy, and physical environments (https://blogs.bmj.com/bmj/2019/10/10/what-will-it-take-to-halve-childhood-obesity-by-2030).

Peter Green’s editorial reminds us that this is the 30th anniversary of the UN Convention on the Rights of the Child and explains how the UK’s newly established National Child Mortality Database can contribute to children’s welfare (doi:10.1136/bmj.l5813). Alongside this, Green sees opportunity in a major social care reform that from this month makes local authorities share legal responsibility for safeguarding children with the police and leaders of clinical commissioning groups.

Away from child health, “I don’t know” might be a useful starting point when considering the latest evidence on hormone replacement therapy and risk of breast cancer (doi:10.1136/bmj.l5928), the effects of adult weight change on mortality (doi:10.1136/bmj.l5584), whether to prescribe statins to low risk patients (doi:10.1136/bmj.l5674), or what to do when a patient is worried about direct-to-consumer genetic testing (doi:10.1136/bmj.l5688).

“I don’t know” is also a probable answer if you are asked to explain the US healthcare system. Julie Rovner best explains it as a “hodgepodge” of public and private programmes that results in 27 million uninsured people, in healthcare costs outstripping income, and in a gridlocked struggle between advocates of government control and free market economics (doi:10.1136/bmj.l5885).

In the spirit of breaking problems down, why not look instead to a country with a far smaller population? Finland’s population of 5.5 million people may not have all the answers, but Finns enjoy a lower infant mortality rate than the UK, claim Santa Claus as a resident, and allow clinicians to forget about work by socialising through song (doi:10.1136/bmj.l4939).